Intersex Genital Mutilation – a Western Version of FGM

Children around the world are subjected to genital mutilation, which constitutes a serious breach of the rights of the child. When procedures are carried out on girl children in countries such as Africa, the Middle East and the Philippines, the practice is called Female Genital Mutilation or FGM. Although the term FGM involves a vast range of rituals from extremely invasive to quite minor, it is universally decried as an abhorrent social practice for which there should be zero tolerance. Yet intersex children in the West are subjected to equivalent treatment, and their plight has been ignored or endorsed. In the last few years, the practice has begun to be seen as a form of cruel and unusual treatment, possibly constituting torture. Now referred to as Intersex Genital Mutilation or IGM, it is argued that this is a cultural practice equivalent to FGM and that advocates of children’s rights should work to prevent the abuse of intersex children.

When the Western world first became aware of the ritual practice of female circumcision in a number of African countries, there were shockwaves about the brutality, the indignity and the violence directed primarily at very young girls. Generally performed without anaesthesia, often with blunt instruments, girls were held down by mothers and grandmothers and their genitals were cut. Whether the cutting was minor or extreme, there were and are serious impositions on the girl’s health. The descriptive term for all genital cutting became Female Genital Mutilation (FGM). Although women were both victims and perpetrators, FGM has been understood as an extreme example of patriarchy and male violence.

While the horrors attendant on FGM have passed into our construction of ‘primitive’ cultures, and laws have been introduced to outlaw its practice, we have remained blissfully unaware of an equivalent experience of some young people within our midst. Intersex children are being subjected not just to genital surgery, but have also been sterilised in Western hospitals. Intersex children are at risk of the same abuses of rights as experienced by those affected by FGM. Both groups of children are denied basic human rights including freedom from violence, freedom from gender and sex-based discrimination, the right to bodily integrity and the right to the highest attainable standard of health. The cultural blindness to the plight of intersex children becomes highly attenuated when we recognise that we cast such a strong and unrelenting gaze on those girls and women in our midst who have been subjected to FGM or are at risk of FGM.

In this article, I will discuss why it is appropriate to consider the ‘medical’ treatment of intersex children as Intersex Genital Mutilation (IGM). The emotional claim of FGM should be equally applied to IGM, and it is my position that special protection should be afforded children at risk of IGM. While the efforts to eradicate the practice of FGM in cultures where female circumcision has persisted for hundreds of years are important for the protection of children’s rights, it is shocking that a similar effort has not been expended on behalf of intersex children, where IGM is of recent origin and could be eradicated with a relatively slight political effort. This article aims to take a step towards action against IGM, by naming it for the human rights abuse that it is, and by joining the call for those concerned with the rights of the child to take action.[1]

A Note on Terminology: Interventions on Children’s Genitalia

Circumcision, of one form or another, has been performed as a rite of passage in many cultural and religious communities across time and place. While male circumcision has been considered relatively unproblematic, the cutting of girls’ genitalia is considered to be a gross violation of human rights and a form of extreme violence perpetrated against young girls and women (DeLaet, 2012). The term Female Genital Mutilation (FGM) is the collective name given to several different traditional practices that involve disfiguring or removing part, some parts or the whole of particularly sensitive area of female genitalia. These include: clitoridectomy (the removal of the clitoris with or without removal of the clitoral hood); excision (cutting the hooded clitoris together with partial or total removal of labia minora or the labia majora); infibulation (excision of part or all of the external genitalia with or without sewing the raw edges together or narrowing of the vaginal opening); and any other procedures such as genital pricking, piercing, scraping or incising. This could include, for example, an incision extending from vaginal opening into surrounding tissue with damage to the urinary/urethral opening or rectum and anus. It may, however, be no more than the drawing of blood. While the impact on the child or woman is extremely different depending on the procedure, internationally there is consensus that there should be zero tolerance of FGM (see also Johnsdotter and Essén, 2010; Berer, 2010; Smith, 2011; Wade, 2011).[2]

FGM is generally carried out by a traditional practitioner, who may be itinerant, a woman and/or a family member. It is sometimes performed on a newborn, but is most commonly experienced between four and twelve years of age. In many cases, the physical environment where FGM is carried out is aseptic and the instruments used are not sterile. Describing these practices as ‘mutilation’ rather than ‘cutting’ or ‘circumcision’ was deliberately adopted to capture the horror, disgust and outrage at the practice Costello, Susie, Marjorie Quinn, Allison Tatchell, Lynne Jordan, and Koula Neophytou. “In the best interests of the child: Preventing female genital cutting (FGC).” British Journal of Social Work (2013): bct187

[3]. The term was coined by Hoskens, who was instrumental in capturing and alerting the world community to FGM as violence against women. The term has been adopted by the World Health Organisation and is used in international human rights instruments and domestic legislation.[4] The intersex community is now calling on human rights advocates to use equivalent emotive language to describe their experience of genital intervention – IGM – to recognise the serious and abusive nature of their treatment and to take action to bring about zero tolerance of IGM.[5]

Intersex children are children who are born with physical or biological sex characteristics that do not fit within rigid ideas of male and female bodies. The variations may relate to sexual anatomy, reproductive organs, hormonal patterns and/or chromosomal patterns and it is believed that this affects up to 1.7% of the population, which is the same as the proportion of people with red hair[6]. These presentations of sex characteristics are seen as anomalous, and intersex children are considered by Western medicine as broken bodies in need of fixing[7]. While medical intervention may well be desirable at some point in the life of an intersex person, the treatment with which is the subject of this article is non-consensual, irreversible surgical and hormonal intervention designed to make intersex bodies fit into a more socially acceptable embodiment of being male or female.

As with FGM, there are a range of practices which constitute Intersex Genital Mutilation. These include:

Feminising Procedures: Clitoris Amputation/Reduction, Vaginoplasty, Dilation. These include a procedure outlawed when described as FGM – the removal of the clitoris. Even worse, to my mind, are procedures surgically creating vaginas that are “big enough for normal penetration” (vaginoplasty) but which need to be forcibly dilated by (usually the mother) continuously inserting a solid object into the opening, a practice experienced as a form of rape and child sexual abuse.

Masculinising Surgery: Hypospadias Repair. This is surgery on the penis to relocate the urethral opening to the tip of the penis. An artificial urethra is formed out of the foreskin or skin grafts. This procedure is psychosocial rather than of medical necessity.

Other Unnecessary and Harmful Medical Interventions and Treatments: These include mastectomy, the imposition of hormones, forced excessive genital examinations, medical display, genital photography and human experimentation.[8]

Because this is a Western practice, genital proceedings on intersex children are described as genital surgery and are performed in the relative safety of a sterile hospital environment. This has contributed to the privatisation and secrecy of the experience. Being intersex was considered a matter of shame, as a ‘disorders of sex development’, an aberrant and abnormal in need of fixing and constant medical attention. While more and more lesbian, gay, bisexual and transpeople have come out in public and drawn attention to their experiences, this has not been equally true for intersex people. Until very recently, there was little public awareness of the existence and the treatment of intersex children and adults. The movement for intersex rights is of relatively recent origin, and it has only been into the 21st century that their experience of human rights abuse has been taken seriously.[9] Early in 2017 Hanne Gaby Odiele, a high status model, told the world that she is intersex – recognising that in doing so she was trailblazing in breaking the taboo of silence surrounding intersex people[10].

There are two key difference between the genital cutting that constitutes FGM and the genital intervention in intersex children. The first is the perception that FGM is performed for non-medical or non-therapeutic reasons, while the interventions on the bodies of intersex children are considered to be therapeutic or medically indicated. The second is the accepted lore that the treatment of intersex children is motivated by the belief that genital intervention is ‘in the best interest’ of the child, while FGM is not justifiable as being ‘in the best interest of the child’. However, neither of these differences is real.

The parents of children subjected to FGM love their children and believe that cutting is very much in the child’s interests. Equally the parents of intersex children love their children and believe that genital intervention is very much in the child’s interests. Yet both sets of parents are caught in cultural whirlwinds which dictate the ideological construction of what should and should not be done in the child’s best interests. Just as parents who authorise FGM are insulted and distressed by the idea that they are mutilating their children, parents of intersex children who authorise procedures will be both hurt and incredulous that what they have done with such trepidation and love could be characterised as mutilation. Yet this is an appropriate descriptor of the treatment of intersex children and the terminology of Intersex Genital Mutilation should be adopted to encourage outrage and distress about what is happening to intersex children.

This would not be the case if the first difference, that of the therapeutic nature of the intervention, held true. But current research shows that, like FGM, writing on the bodies of intersex children is cultural and that early medical intervention causes more harm than it overcomes. While most intersex people will seek medical help at some point in their life, this does not justify premature intervention. So, much hangs on the question of whether the treatment of intersex children should be characterised as therapeutic. And, while there is no doubt that there are some circumstances where this is the case, a question remains as to whether this is true for all or most intersex ‘normalisation’ procedures, a matter to which we will return below.

The Best Interest of the Child

As a general rule, parents take their roles seriously and act in the interest of the child to the best of their ability. But this is a complex thing to do and a high standard to achieve, because, at a personal level there is a need to balance the needs of multiple children, partners and work, while at a societal level there are social, religious, cultural and community values that come into play. Further, every action is taken in a context of which those outside may not be aware. We can not assume that a parent denying their child a drink of water or locking the child in a dark cupboard is acting inherently against the interest of the child – because the water may be poisonous and the cupboard a safe place to avoid serious risk of violence or even death.

It is reasonable to assume, though, that subjecting a child to violence cannot be in the child’s best interest. This leaves aside the fact that medical treatment would be and is viewed as a form of violence, were it not for the consent of the patient or someone consenting on that person’s behalf. On the other hand, the rites of passage in many communities involve an ordeal of some sort which often places the child at risk. For communities practicing FGM, genital cutting is an age-old tradition and the harm of not subjecting girls to the procedure has historically been considered to be greater than the risks of the procedure. In these communities, FGM is a deeply entrenched cultural value involving the sense of what it means to be a woman, to be beautiful, to have an identity and to be included in the community. According to Costello et al, FGM

is intertwined with ‘family honour, virginity, chastity, purity, marriageability and child bearing virtues’ for girls and women. The particular and specific meanings, beliefs, myths and their associated practices vary between regions, localities and ethnic groups. They are so deeply entrenched that [FGM] is considered a normal and necessary aspect of raising a girl properly. [11]

This explains why, despite much international effort, FGM continues to be practiced. Women are concerned about the risks of harm to themselves and their children, but they are fearful about being excluded from their community, the real possibility of violence and the inability to marry as a result of not performing FGM on their daughters. Whether the source of the belief and practice is religion, culture or custom, parents do not make the decision to perform FGM on their daughters lightly.[12]

The World Health Organisation has noted that there are immediate, obstetric, sexual functioning & psychological risks for girls who are victims of FGM.[13] These include severe pain and risk of severe bleeding that can lead to shock and death, local and systemic infections, abscesses, ulcers, delayed healing, septicemia, tetanus, and gangrene. FGM is also known to result in long term chronic pain, repeated urinary infections; frequent reproductive tract infections and infertility; and prolonged and obstructed labour. FGM is also a traumatic experience, leading to Post Traumatic Stress Disorder and other psychosocial problems. Even if performed in a hospital, the procedure can result in severe pain, shock, excessive bleeding, difficulty in passing urine, infections, psychological trauma and death.[14]

For intersex children, too, the removal of or damage to healthy, normal genital tissue interferes with the natural functioning of the body and causes several immediate and long-term health consequences. As with FGM, IGM practices carry a large number of known risks of physical and psychological harm. As with FGM, these include loss or impairment of sexual sensation, poorer sexual function, painful scarring, painful intercourse, incontinence, problems with passing urine, increased sexual anxieties, problems with desire, less sexual activity, lifelong trauma and mental suffering. Survivors of IGM experience elevated rates of self-harming behaviour and suicidal tendencies which are comparable to those who have experienced physical or child sexual abuse, impairment or loss of reproductive capabilities and lifelong dependency on daily doses of artificial hormones.

While the procedures on intersex children are conducted in hospitals under the authority of the medical profession, the reasons for IGM are almost identical to the justifications of FGM. Parents believe the intervention is in the best interest of the child for cultural reasons which include beauty, looking normal (ie the same as other children in the culture), marriageability, proper sexuality and being a ‘proper woman’ or a ‘proper man’. That this is cultural is apparent because this is not a long-standing practice or one associated with a religion. It is part of Western secular culture and modern and late-modern views of sex, gender and personhood.

Rather than recognising the wide variety of normal sex characteristics, the birth of an intersex child is viewed as a tragedy best responded to secretly and as a matter of urgency. Yet atypical genitals are not in themselves a health issue and surgical intervention to ‘normalise’ genitalia is unnecessary for gender assignment. While there are some intersex conditions which require surgery for medical attention, such as the presence of cancer or the need to create an opening for urine to exit the body, these are very much the exception. Most surgery to which intersex children are subjected could wait until children are able to fully participate in decisions about their bodies, including being informed of the benefits and risks of surgical intervention.

Seeking to ensure decisions about surgery on intersex children are made in the best interests of the child is difficult when the medical establishment insists that the child’s interest is trumped by matters pertaining to the family. Morgan Carpenter comments that: in the 2006 Consensus Statement of protocols for the management of the bodies of intersex children, drawn up by doctors, the basis for recommending ‘normalising’ surgical intervention is to “minimise family concern and distress, facilitate parental bonding and mitigate the risks of stigmatisation”; a 2012 Swiss national bioethics report concluded that interventions addressing stigma, familial and social integration “run counter to the child’s welfare; and a 2013 Australian Senate inquiry found in that psychosocial and cultural rationales for surgical interventions are a “circular argument that avoids the central issues”.[15] These issues, surely, are those pertaining to the rights of the child.

Therapeutic & Non-Therapeutic Treatment

The argument about whether either the practice of FGM or IGM can be seen as justifiable turns on the question of medical benefit and medical necessity. With respect to FGM, there is consensus that there are no medical benefits to the practice and that attempts to defend FGM on the basis of medicine are highly problematic. Most discussion of the dangers of the medicalisation of FGM are in response to bringing the practice of FGM to the far safer environment of a hospital or clinic, with the procedure being conducted by a health professional. While this addresses many of the health risks of FGM, it fails to tackle the inherent underlying abuse of human rights.[16] This is the invasive, non-consensual, irreversible mutilation of the child’s genitalia. It matters not that the social, religious or cultural benefits to the child might be significant, because the positive psycho-social outcomes are insufficient to outweigh the harm of the procedure.

Yet in the case of intersex children, the invasive, non-consensual, irreversible mutilation of the child’s genitalia continues because the psycho-social benefits to families, who will otherwise be embarrassed and uncomfortable with their child’s gender and appearance, is seen to be sufficient to justify much of the surgery and medical intervention to which intersex children are subjected. The explanation for this lies in the history of treatment and its underlying ideology. It also lies is the secrecy, believed to be in the child’s best interest, which often extends to parents and results in the inability of parents to give informed consent to the procedure.

The idea of ‘normalising’ intersex infants has its roots in the 1950s, with the belief that a child’s gender identity was not based in biology but in upbringing and nurturing.[17] It was believed that it didn’t matter which sex was assigned, so long as the gender role was constantly reinforced socially – in the family, the school and in whatever interactions the child has. It was considered that best results from such assignments were achieved when the babies were not older than around two years of age. This is because emphasis was placed on the newborn’s ability to pass for one sex or the other, thus meeting social expectations.[18]

The most famous case of gender assignment involved a botched circumcision in which the boy’s penis was accidentally burnt.[19] The doctors, led by John Money, decided that the solution was further surgery (beginning at the age of 22 months) to make the child a girl. Despite an inordinate amount of invasive medical procedures, in his teen years the child transitioned back to his original male identity. Nonetheless, Money’s view of the malleability of gender became the dominant viewpoint among physicians and doctors. For 70 odd years intersex children have continued to be used as subjects of an experiment into the nature and malleability of gender.

Knowledge of the lived experience of intersex adults is essential to understand IGM. The account of Christiane Völling, who was born with “indeterminate external genitalia” and was raised as a boy, is one amongst many and is not atypical. She writes:

The castration [removal of internal testes] that I suffered and the paradoxical administration of high-dose testosterone, considered as necessary, resulted in physical and psychological damage such as hot flashes, depression, sleeping disorders, early osteoporosis, the disappearance of my sexuality and my reproductive capacity, trauma linked to the castration, lesion of the thyroid glands, change in my brain’s metabolism and my bone structure as well as many other secondary effects and lesions. The taking of testosterone has caused the development of a typical male hair pattern, a masculine beard, the loss of all my hair linked to the impact of the androgens, a masculinisation of my previously feminine voice, the masculinisation of my facial features and the production of a male anatomy despite female predispositions. The male genitalia surgically constructed have caused irreversible damage such as chronic urinary infections, disorders of urination, strictures and scarring. These interventions have made me lose all my innate feeling of belonging to a sex and all sexual behaviour.

Like many other survivors of intersex ‘normalisation’, Christina only discovered what had happened to her many years after the event.[20] And like many other survivors of IGM, Christina’s doctors and parents had chosen the wrong gender. This leads intersex people to seek access to medical treatment to transition from their assigned to their chosen gender. So, much of the trauma and the cost, both to intersex people and to society at large, could be avoided by the simple expedient of delaying medical intervention until the child can give informed consent.

There is mounting evidence that the ‘normalising’ procedures imposed on intersex children are experimental in nature.[21] The medical literature does not support the position taken by doctors that surgery on intersex children is in their best interest. The harm done by ‘normalizing’ medical procedures on young children is beginning to be recognized as significant. A 2017 Report by Zillén, Garland and Slokenberga commissioned by the Council of Europe confirmed the harm of the procedures and assessed the research-base for the interventions. Their findings are:

All evidence-based reviews acknowledge that harms have occurred and may continue to occur for patients, including pain, dysfunction, error in gender assignment and harm to their quality of life.[22]

The long-term studies about the safety and efficacy of ‘normalising’ treatments do not exist, and that even the best studies “lack the necessary detail to base further recommendations” on future care for individual children.[23]

There is no consensus among expert practitioners as to the need, timing, safety, or efficacy of these procedures.[24]

After a thorough review of the literature, Zillén, Garland and Slokenberga were only able to find three circumstances in which there may be medical necessity to perform surgery on intersex infants and young children.[25] These are not among the common diagnosis of intersex children. So the insistence of many doctors that ‘normalizing’ treatment is needed at the earliest possible date is inconsistent with the evidence.[26]

The enormity of this claim is evident, yet it is based on a thorough analysis of the medical literature as well as on the reported lived experience of intersex people. So how is it possible that these practices continue to be carried out in major hospitals across the globe? And how is it that parents, whose decisions are expected to be taken in the best interests of the child, continue to authorise procedures and cooperate in maintaining the regimes established by medical practitioners?

The answer to these questions is that medical practice prioritizes social and cultural norms over the rights of the child. Parents rely on medical practitioners to provide them with the information that they need to make the best possible decisions on behalf of their children. That information would of necessity address the non-therapeutic and experimental nature of any proposed ‘normalising’ treatment and the potential harms of intervening without the child’s involvement in any decision about gender assignment. If adequate and appropriate information is not provided, it will not be possible for parents to give informed consent to treatment. If there has been no informed consent, the element which transforms medical intervention from violation and violence will not be present. IGM will then be a criminal offence in its own right, over and above the possibility that it is outlawed by law criminalising FGM.

FGM, IGM & The Rights of The Child

The major human rights pertaining to children’s health and well-being, and to children’s rights generally, are to be found in the Convention on the Rights of the Child (CROC). The principle that the best interest of the child is to be the primary consideration in decisions affecting children is enshrined in Article 3. As we have seen, neither FGM nor IGM can be demonstrated to be procedures in the best interest of the child.

For survivors of FGM and children at risk of FGM, Article 19 which is concerned with protecting children from violence, including FGM,[27] and Article 24 which deals right of the child to the highest attainable standard of health are the most pertinent. The Committee on the Rights of the Child has confirmed that one should take a holistic approach to health, which places the children’s right to health within the broader framework of international human rights obligations. This approach involves a consideration of the physical and emotional circumstances of children’s lives, including the ways in which they are protected from or exposed to harm, and a consideration of all aspects of the child’s well-being, including being treated with dignity and respect. Further, Article 24 (3) requires States Parties to take all effective and appropriate measures to abolish traditional practices prejudicial to the health of children. This would include the practice of FGM, which is acknowledged to be a harmful traditional practice.[28]

A great many of the provisions of CROC apply to the situation of intersex children. These include not only Article 3, 19 and 24, but also Article 2(non-discrimination), Article 5 (the evolving capacities of the child), Article 6 (child survival and development), Article 8 (the right to an identity) and Article 16 (the right to privacy). A strong case for an abuse of the rights of intersex children could be built from the jurisprudence surrounding these rights. However, there are two other rights which should stand at the centre of the claim for recognition of IGM and the wrongs experienced by intersex children and adults.

The first of these is Article 12, which provides that children have the right to express their views and be heard in matters affecting them. The weight to be given to the child’s view is to be determined by the age and maturity of the child. While Article 12(2) makes special reference to judicial and administrative proceedings affecting the child, it is hard to think of a matter more central to the child than bodily integrity and gender identity. The threat of significant and irreversible surgical intervention that will reverberate within the core of the child’s being is at least equivalent in significance to the child’s life as a decision to remove a child from biological parents or to engage the child in the criminal justice system. It is therefore incredibly important to ensure that any medical decision that can be deferred until the child is old enough to understand the nature and consequences of the proposed intervention, to express that view, to be heard and to be taken seriously. As a major reason for considering surgical intervention in intersex children to be IGM is that it is conducted without informed consent, it would be a breakthrough to allow children to consent on their own, if they are old enough, or together with a responsible adult.

The other human rights strategy beginning to be used to address IGM is to have it recognised as a form of “torture or other cruel, inhuman or degrading treatment”. The UN Committee on the Rights of the Child, the UN Committee on Torture and the UN Committee on Persons with Disabilities have all made recent comments in country reports to this effect[29]. Article 37 of CROC provides that no child shall be subjected to torture or to “cruel, inhuman or degrading treatment” and Article 39 requires States to take “all appropriate measures to promote physical and psychological recovery and social reintegration of a child victim of: … torture or any other form of cruel, inhuman or degrading treatment”. The UN Committees have not only articluated IGM in this way. They have also requested information about reparations payable to survivors of IGM. Given that most jurisdictions have statutes of limitations preventing legal action by adults for infractions they experienced as children, the availability of a claim for compensation will not only help pay for the medical problems created by IGM, but will also make actors accountable for their actions. Establishing that IGM is a form of torture, cruel, inhumane or degrading treatment is a significant achievement for the emerging anti-IGM lobby.

Conclusion

For victims of FGM, the act is authorised by parents, but the oppression can be understood as an expression of misogyny and patriarchy. For victims of IGM, the act is authorised by parents, but the oppression can be understood as an expression of patriarchy and the power of medicine. In both cases, it is the need for cultural normalisation that ultimately justifies the procedure. Where FGM is or has been practiced, it was defended because it was culturally encoded with ideas of beauty and marriageability, and girls needed to be ‘normalised’ to ensure their genitalia matched social expectations.

Where IGM is practiced, it is culturally encoded with notions of gender, to ensure that genitalia matched social expectations, ideas of beauty and marriageability. Popular Western culture has a focus on bodily perfection and has resulted in women taking extreme measures to conform with standards of beauty. Women subject themselves to cosmetic surgery, including breast enhancements, facelifts and weight reduction. They also engage in modifications to their genitalia. In late modern society, despite the sexual revolution and other movements designed to bring about equality, the idea of ‘maleness’ and ‘femaleness’ has become rigid and bifurcated. Constricting ideas of how one should be, have led to violence against anyone seen as gender-nonconforming. Intersex bodies are therefore to be normalised.

The logic supporting intersex ‘normalisation’ is directly parallel to the logic of FGM. Genital mutilations, whether mandated by traditional or modern culture, are mutilations of the genitalia. If we are outraged at one practice, we must be outraged by both. IGM is simply a Western method of controlling and regulating sex and gender, with violence perpetrated against intersex children in the name of medicine. IGM is no more and no less than a Western version of FGM.

* Independent Human Rights Scholar & Disability Advocate; Former Director Australian Human Rights Centre, University of NSW. I’d like to thank Danielle Jones-Resnik & Morgan Carpenter for their contributions to this paper. The view expressed are those of the author.

[1] The parallels between IGM and FGM have been explored by other scholars including Nancy Ehrenreich and Mark Barr. “Intersex surgery, female genital cutting, and the selective condemnation of cultural Practices.” Harv. CR-CLL Rev. 40 (2005):71 and

[2] While this is not the place to discuss the issue of consenting adult women, a solid case has been made that there is a direct parallel between FGM and Western practices of genital alteration, designer vaginas and cosmetic procedures such as breast implantation. To allow the latter but ban the former can only be understood as a judgement of the inferiority and primitive nature of non-Western cultures.

[3] Susie Costello et al report that practicing communities consider the term FGM offensive, alienating, disempowering and racist. Nonetheless the terminology has been effective in raising attention about the problem and campaigning for change, and my concern here is achieving a similar profile for intersex children, with the concomitant change in social practice. Costello, Susie, Marjorie Quinn, Allison Tatchell, Lynne Jordan, and Koula Neophytou. “In the best interests of the child: Preventing female genital cutting (FGC).” British Journal of Social Work (2013): bct187

[10] http://www.bbc.com/news/world-europe-38730291. In 2016 an intersex character was portrayed for the first time on mainstream television in MTV’s Faking It http://www.newnownext.com/faking-it-intersex/04/2016/

[12] Amos Idowu points to historical, cultural and social factors combined with illiteracy as the basis for FGM in Nigeria. See “Effects of forced genital cutting on human rights of women and female children: the Nigerian situation.” Law, Democracy & Development 12.2 (2008): 11-122.

[21] Id “Throughout this report, however, much of the medical literature cited reflects candid acknowledgments that ongoing practices lack scientific support or that the causes of adverse effects on children from interventions are poorly understood. Given that even more severely negative outcomes are almost certainly not reported in the literature and that much of the reported data cannot be verified, any authority concerned for the rights of children should be concerned as much by what is not known as by what is known, especially as many known troubling practices have not been stopped in the wake of scientific skepticism and criticism.” At p74

[23] The Annecy Working Party, a gathering of fifty of the world’s leading practitioners in Annecy, France, warned that (1) “quality of life” studies on patients into adulthood are lacking and are “poorly researched”, (2) the overall impact on the sexual function on children surgically altered is “impaired” and (3) the claim that gender development requires surgery is a “belief” unsubstantiated by data. Per Sarah Creighton and others, ‘Timing and Nature of Reconstructive Surgery for Disorders of Sex Development – Introduction’ (2012) 8 Journal of Pediatric Urology 602.

[24] Peter A Lee and others, ‘Global Disorders of Sex Development Update since 2006: Perceptions, Approach and Care’ (2016) 85 Hormone Research in Paediatrics 158. Cited by Zillén et al (2017) at p43

[26] “Cancer risks to children with undescended testicles in most cases do not require gonad removal in infancy and can be delayed until late puberty or early adolescence in some cases, or even into adulthood. Older children with the need to menstruate may require surgical intervention to prevent vaginal pooling and other related harms, but an adolescent in such circumstances might prefer facilitation of a male gender assignment rather than vaginoplasty or may prefer temporary measures to facilitate menstruation without such procedures. None of the aforementioned reviews have identified any other procedure as medically necessary or confirmed to have a balance of long-term benefits from gender-“normalizing” interventions in infancy.” Ibid

[27] See Joint general recommendation No. 31 of the Committee on the Elimination of Discrimination against Women/general comment No. 18 of the Committee on the Rights of the Child on harmful practices CEDAW/C/GC/31-CRC/C/GC/18 14 November 2014